Care Coordinator Registered Nurse - Remote in Michigan

McLaren Health Care; Flint (MI); Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Full-time schedule

8:00am–5:00pm shifts

Remote work option

Job summary

McLaren Health Care in Michigan seeks a Care Coordinator Registered Nurse to support patients remotely. You will assess, plan, implement, coordinate, monitor, and evaluate care needs using clinical and community resources to promote quality outcomes.

You will work within an interdisciplinary team to prevent hospitalizations and ER visits. The role emphasizes care coordination for chronically ill populations, with required Michigan RN licensure and 3+ years of clinical nursing experience.

Qualifications

• RN with a valid unrestricted Michigan license.
• Three years of clinical nursing experience serving chronically ill patients.
• Preferred: RN, BSN; three years in health plan/ Physician Organization with care coordination or population health.

Responsibilities

• Provides telephonic and face-to-face comprehensive assessment and care management services as part of an interdisciplinary team.
• Uses risk assessment tools to target high-risk populations.
• Assesses ongoing health, educational, and psychosocial needs of patient/caregiver.
• Follows up after transitions, coordinates care, and educates on discharge instructions.
• Uses clinical judgment to determine level of care and collaborate with PCP and team.
• Develops individualized care plans and revises as needed.
• Supports patient self-management to empower self-care.
• Monitors high-risk patients to prevent acute episodes.
• Implements protocols based on guidelines and risk stratification.
• Coordinates care with PCP, patient/caregiver, McLaren Health Care, and community services.
• Fosters team-based care with patient involvement.
• Ensures continuity of care beyond practice boundaries.
• Acts as liaison to hospitals, specialists, and post-acute services.
• Maintains documentation of care management activities.
• Works with leadership to evaluate processes and drive improvements.
• Keeps up with literature on engagement and care management strategies.
• Performs other duties to maintain department operations.

Skills

Care coordination

Telephonic care management

Geriatrics experience

Chronic disease management

Patient advocacy

Education

RN License

BSN (preferred)

Job description

The McLaren system includes 12 hospitals across the state, ambulatory surgery centers, imaging centers, a 730-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 242,000 Michigan lives, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network, and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 93,000 network providers throughout Michigan.

Care Coordinator Registered Nurse - Remote in Michigan

As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes. Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric. Provides targeted interventions to avoid hospitalization and emergency room visits.

Essential Functions and Responsibilities:

1. Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.

2. Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations.

3. Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver.Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

4. Provides follow up with patient/family when patient transitions from one setting to another.Completes timely post-hospital follow up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.

5. Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community.

6. Responsible for developing a comprehensive individualized plan of care and targeted interventions.Continually monitors patient/family response to plan of care and revises the care plan as indicated.

7. Provides patient self-management support with a focus on empowering the patient/caregiver to build capacity for self-care.

8. Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

9. Implements clinical interventions and protocols based on risk stratification and evidenced-based clinical guidelines.

10. Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other disciplinary team members.

11. Fosters a team approach and includes patient/caregiver as active members of the team.

12. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.

13. Serves as liaison to acute care hospitals, specialists, post-acute care services and community services.

14. Demonstrates excellent written, verbal and listening communication skills, positive relationship building skills, and critical analysis skills.

15. Maintains required documentation of all care management activities.

16. Works with MPP Medical leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.

17. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates them into clinical practice.

18. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.

Required:

• RN with a valid unrestricted Michigan license.
• Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics.

Preferred:

• RN, BSN.
• Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health.
• Telephonic care management experience.
• Home care and/or hospice experience.
• Complex Care Management course completion or CCM.

Additional Information

• Schedule: Full-time
• Daily Work Times: 8:00am-5:00pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.

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McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employmentwithout regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status,national origin, disability, genetic information, height or weight, protected veteran or other classificationprotected by law.